S. Barry Eiden, OD, FAAO
President and Medical Director of North Suburban Vision Consultants, Ltd.
With the aging of our population we are faced with increasing challenges regarding the ongoing eye health of our senior citizens. Although there are significant and potentially devastating eye diseases that particularly afflict the elderly, advances in medical technology are allowing eye specialists to diagnose and treat these diseases earlier and much more effectively. More exciting is the potential to eventually prevent these diseases. I would like to review some of the most common eye health issues that face us as we age and how we are addressing them. The future looks bright for us in this regard. We can hope and expect to experience the visual wonders of our world well into our golden years!
Internally within our eye, located just behind the colored iris is a crystalline focusing lens. When this lens develops cloudiness, translucencies, and opacities we call them cataracts. If significant enough the cataracts will blur vision, they can cause increased glare symptoms, and can reduce vision significantly if more advanced. Early cataract development typically induces frequent changes in glasses prescription, but still allows light to focus well. As the cataracts progress over time they will eventually reduce vision and can not be corrected by changing glasses prescriptions. It is then that surgery is required to remove the cloudy crystalline lens and replace it with a synthetic implant lens. Cataract surgery is the most commonly performed surgery in the United States for people over 65 years of age. Over 1.5 million cataract surgeries are performed each year!
Cataracts can result from many causes. By far the most common cause is simple aging of the internal lens. Biochemical changes associated with the aging process cause the internal lens to loose its clarity. As such, age related cataracts are not actually a disease, but a normal aging process just like the graying of our hair or wrinkling of our skin. Other causes of cataract include; eye trauma, effects of certain drugs, effects of some medical conditions/diseases, and even congenital cataracts occur in babies.
There have been many advancements in cataract treatment recently. Today the surgery is quite minimally invasive and is performed as an outpatient procedure under topical anesthesia. Patients regain clear vision after surgery within a matter of a few days or less! Gone are the days of eye patches and bed rest following cataract surgery. Today the accuracy of calculating the power of the implant allows us to virtually predict the visual outcome for our patients. It truly has become a refractive procedure similar to LASIK laser eye surgery in that we can target vision correction prior to surgery. If one desires to have clear vision far and only use reading glasses after cataract surgery, we can do this! We have the ability to correct astigmatism with implants and now even implant bifocal/multifocal lenses that have allowed many of patients to eliminate the need for glasses altogether!
What about the concept of cataract treatment without surgery and possible prevention? Well research is going on all over the world in this regard. Initial outcomes from some studies have shown some promise in finding the route cause of age related cataracts and therefore the next logical outcome will be methods to prevent their formation. As of today we can say that certain environmental conditions may increase our risk to develop cataract. Exposure to UV light is a risk factor for cataracts as is smoking. A recent study from Harvard University Women’s Hospital showed that certain nutritional elements were in low concentration in patients who developed cataracts. These include lutein and zeaxantan. However vitamin C, and E have not been noted to help prevent cataracts. Much more research is needed and is going on.
The macula is the central area of the retina. It has the highest concentration of light sensitive photoreceptors and as such provides us with our central vision detail. When we look at something (reading, watching TV, driving, even looking at someone’s face) we aim our eyes to but the target in the macula.
Macular degeneration is a group of diseases that result in damage to the macula. The most common form of macular degeneration is age related macular degeneration (ARMD). This disease afflicts people over 55 to 60 years of age and is the most common cause of legal blindness in the elderly. Understand that legal blindness only refers to a loss of visual acuity (seeing letters on an eye chart) or a loss of a specific amount of peripheral vision. In macular degeneration only central vision is affected, there is no impact on peripheral vision. As such, people with ARMD (even severe forms) never become totally blind. In fact they maintain quite good mobility and get around quite well. They simply can not see central detail. This has great impact on one’s life. In some cases it results in the lack of ability to read, see detail on TV, loss of driving ability, etc. It can range in severity from almost no impact on vision all the way up to severe central vision loss. Those persons with advanced ARMD often loose independent living functions and may even suffer from depression as a result. There are two basic forms of ARMD. The first and most common is the dry or atrophic form where cells in the macula degenerate gradually with associated central vision loss. The second form is the wet form or exudative form of ARMD. This form is typically acute in onset and has hemorrhage and other retinal fluid leakage associated with it. Both forms can be severe, however the dry form can be quite mild in many patients.
Treatment for macular degeneration continues to progress and today we can not only halt progression of the disease for many patients, but in some cases actually reverse the disease to some degree. Most of the effective treatment methods used today are indicated only for the wet form of ARMD, however we are continuing to conduct research on treatments for dry ARMD as well. The most advanced therapy used today involves the injection of drugs into the eye to inhibit the leakage and abnormal blood vessel growth associated with wet ARMD. Many patients have done well with these anti-VEGF injections, unfortunately the majority of ARMD patients still are waiting for effective treatments. The future appears bright in consideration of the research going on.
Most importantly we need to determine how to prevent ARMD. The key likely is in understanding the underlying processes that result in ARMD. Our knowledge in this area is expanding exponentially. Today we have been able to identify various risk factors for ARMD. Some of them are modifiable and as such we can do something about them. Key ARMD risk factors include; family history of the disease, exposure to UV, smoking, obesity, and the levels of protective photopigments in the macula. Two key photopigments (lutein and zeaxanthan) naturally are located in the macula. They serve to protect the macula from phototoxic effects of short wavelength light and the degenerative effects of free radical accumulation. People gain these photopigments from their diet. Foods high in these elements include dark green leafy vegetables such as spinach and collard greens (among others). Today we can measure the levels of protective photopigments in the macula. For those who have low levels we can increase them by diet modifications and the use of supplements that contain high levels of them.
Our future looks bright for both the treatment of macular degeneration and its ultimate prevention.
Glaucoma is an eye disease that damages the optic nerve. It is associated with internal fluid eye pressure that is higher than the optic nerve can tolerate. Glaucoma is generally an insidious disease in that it is slowly progressive yet has virtually no symptoms until the disease is advanced. At that point vision is severely reduced and treatment is not very effective. Glaucoma if not diagnosed and treated can result in total blindness. This is why it is critical to diagnose glaucoma in its early phases, before symptoms develop and when treatment is highly effective. The good news is that today we are able to diagnose glaucoma at very early stages and our treatments are excellent. In my view there virtually is no reason why a person who receives good quality eye care today should ever loose vision from glaucoma.
Vision loss from glaucoma typically effects peripheral vision first and ultimately effects central vision resulting in blindness. Early diagnosis and treatment is key in the prevention of glaucoma related vision loss. Although glaucoma can afflict people of all age groups, the most common form of glaucoma (primary open angle glaucoma) is far more common as one ages and rarely is found in people under the age of 40.
By new methods of risk factor assessment for glaucoma we now can institute treatment in a preventative way, thus avoiding loss of vision. We have amazing new and highly sensitive diagnostic tests that can detect the most subtle influences of glaucoma on the eye and vision system. When we detect such changes or determine that significant risk factors exist for glaucoma development we will begin treatment. Current glaucoma treatment is primarily conducted with topical eye drop medications. Well over 95% of our patients are successfully managed with these drops. Today’s glaucoma drops are safer, have far fewer side effects, and are used much less frequently each day (typically one drop per day for most patients) when compared to glaucoma treatments used years ago. New research is allowing us to better understand the mechanisms behind glaucoma along with the strong genetic components associated with the disease. New drugs are continually being developed along with laser treatments, surgical methods, and also the potential for genetic manipulations to prevent the disease.
We have reviewed three of the most common eye health conditions that affect the elderly (cataract, macular degeneration, and glaucoma). Many other eye diseases exist that are associated with older individuals. Research is allowing your eye doctors to diagnose these diseases at earlier phases, institute more effective treatments, and to also discover how to prevent them. The most important thing you can do is to see your eye doctor regularly. He or she will provide you with care based on the most up to date information and technology.
For more information on diseases that effect the elderly and much more eye and vision related information please visit our website at www.nsvc.com and our practice blog at www.nsvc.com/blog.